Medical AHIMA-CCS : Certified Coding Specialist (ICD-10-CM) Exam

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Exam Number : AHIMA-CCS
Exam Name : Certified Coding Specialist (ICD-10-CM)
Vendor Name : Medical
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AHIMA-CCS test Format | AHIMA-CCS Course Contents | AHIMA-CCS Course Outline | AHIMA-CCS test Syllabus | AHIMA-CCS test Objectives

Number of Questions on exam:
=> 97 multiple-choice questions (79 scored/18 pretest)
=> 8 medical scenarios (6 scored/2 pretest)
Exam Time: 4 hours – no breaks
Domain 1 – Health Information Documentation (8-10%)
1. Interpret health record documentation using knowledge of anatomy, physiology, clinical indicators and disease processes, pharmacology and medical terminology to identify codeable diagnoses and/or procedures
2. Determine when additional clinical documentation is needed to assign the diagnosis and/or procedure code(s)
3. Consult with physicians and other healthcare providersto obtain further clinical documentation to assist with code assignment
4. Compose a compliant physician query
5. Consult reference materialsto facilitate code assignment
6. Identify patient encounter type
7. Identify and post chargesfor healthcare services based on documentation

Domain 2 – Diagnosis & Procedure Coding (64-68%)
1. Select the diagnosesthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the diagnosesthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, tables, and definitions of the classification system to select diagnoses, conditions, problems, or other reasonsfor the encounter that require coding
4. Sequence diagnoses and other reasons for encounter according to notations and conventions of the classification system and standard data set definitions(such as Uniform Hospital Discharge Data Set [UHDDS])
5. Apply the official ICD-10-CM coding guidelines
1. Select the proceduresthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the proceduresthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, and definitions of the classification system and/ornomenclature to select procedures/servicesthat require coding
4. Sequence procedures according to notations and conventions of the classification system/nomenclature and standard data set definitions(such as UHDDS)
5. Apply the official ICD-10-PCS procedure coding guidelines
6. Apply the official CPT/HCPCS Level II coding guidelines

Domain 3 – Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (6-8%)
1. Select the principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and proceduresthat require coding according to UHDDS definitions and Coding Clinic
2. Assign the present on admission (POA) indicators
3. Evaluate the impact of code selection on Diagnosis Related Group (DRG) assignment
4. Verify DRG assignment based on Inpatient Prospective Payment System (IPPS) definitions
5. Assign and/or validate the discharge disposition

DOMAIN 4. Regulatory Guidelines and Reporting Requirements for Outpatient Services (6-8%)
1. Select the reason for encounter, pertinentsecondary conditions, primary procedure, and other proceduresthat require coding according to UHDDS definitions, CPT Assistant, Coding Clinic, and HCPCS
2. Apply Outpatient Prospective Payment System (OPPS) reporting requirements:
a. Modifiers
b. CPT/ HCPCS Level II
c. Medical necessity
d. Evaluation and Management code assignment (facility reporting)
3. Apply clinical laboratory service requirements

DOMAIN 5. Data Quality and Management (2-4%)
1. Assess the quality of coded data
2. Communicate with healthcare providersregarding reimbursementmethodologies, documentation rules, and regulationsrelated to coding
3. Analyze health record documentation for quality and completeness of coding
4. Review the accuracy of abstracted data elementsfor database integrity and claims processing
5. Review and resolve coding edits such as Correct Coding Initiative (CCI), Medicare Code
Editor (MCE) and Outpatient Code Editor (OCE)

DOMAIN 6. Information and Communication Technologies (1-3%)
1. Use computer to ensure data collection,storage, analysis, and reporting of information.
2. Use common software applications(for example, word processing,spreadsheets, and email) in the execution of work processes
3. Use specialized software in the completion of HIM processes

DOMAIN 7. Privacy, Confidentiality, Legal, and Ethical Issues (2-4%)
1. Apply policies and proceduresfor access and disclosure of personal health information
2. Apply AHIMA Code of Ethics/Standards of Ethical Coding
3. Recognize and report privacy and/or security concerns
4. Protect data integrity and validity using software or hardware technology

DOMAIN 8. Compliance (2-4%)
1. Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards
2. Monitor compliance with organization-wide health record documentation and coding guidelines
3. Recognize and report compliance concerns

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Medical (ICD-10-CM) outline

ONC Coordinator Outlines New Vistas for Telehealth, Unblocked fitness information, and patient id | AHIMA-CCS test Questions and PDF Download

Micky Tripathi, PhD, MPP, who holds a master's degree in public policy from Harvard university, took the reins of the department of health and Human services workplace of the countrywide Coordinator for health information know-how (ONC) on the first day of the Biden administration in January.

Tripathi isn't any stranger to the thorny concerns on the heart of healthcare IT, equivalent to scientific record interoperability, standards, and certifying electronic health checklist software. His previous two decades of labor within the field let him hit the ground running. He most these days worked as chief alliance officer for inhabitants fitness administration expertise company Arcadia, up to now served as president and CEO of the Massachusetts eHealth Collaborative, and has been on the board of administrators of the HL7 FHIR basis, CommonWell fitness Alliance, and The Sequoia assignment.

Tripathi recently granted an interview to HealthLeaders. Following are excerpts from the dialogue, calmly edited for space and clarity. part 2 of this interview takes a deep dive into the April 5 ONC counsel blocking off rule.

HealthLeaders: With the new administration, what are probably the most enormous fitness know-how policy changes that could have an effect on hospitals and fitness techniques? and how can leaders prepare for them?

Micky Tripathi: I don't know that there are lots of alterations per se. I think or not it's more pretty much things that have been within the pipeline, and that are now being enacted. We're attempting to motivate as quickly enactment as feasible, in the regulatory structure we now have. So in case you feel about issues like assistance blocking off, as an instance, and the 21st Century remedies Act, with TEFCA (trusted change Framework and customary agreement), these had been handed and signed with the aid of President [Barack] Obama and vp [Joe] Biden in December 2016, and the previous administration spent time engaged on implementation of that law that became signed via President Obama.

Now we're putting into impact and attempting to do every little thing we can to speed up it, because it's proceeded a bit bit too slowly from my perspective. So now, of route, there are timelines already constructed into laws, so it's no longer as if we modified these. but i am doing every thing i will be able to to are attempting to evangelize with the trade that they should still be moving forward of the specific regulatory timelines, to the extent that they could.

Micky Tripathi, PhD, MPP, national Coordinator for health information expertise (photograph Courtesy of ONC)

HL: With the upward thrust of telehealth, especially in the ultimate yr, what position will ONC play to be sure that the boundaries that have been lifted could be completely modified, so patients can entry their doctors this manner going forward?

Tripathi: ONC would not at once play a task there. The intent, and here is variety of a delicate factor in the health IT regulatory area, is that ONC is really an enabler of different groups who have company wants. We do not exit and just certify methods on our personal. Telehealth can be a good example. ONC doesn't really have the authority, nor would we just exit and say, "Oh there is a set of technologies that we suppose need standardization, so let's go and begin certifying these, or delivery making these more necessities-based mostly."

we'd comply with an company like CMS (facilities for Medicare & Medicaid functions), should still they make a call, for example, that they're going to preserve the payments that they begun to enable all the way through COVID. it truly is when ONC would come into play and say, "ok, now we support CMS, who's the enterprise proprietor in developing a group of necessities that then get put into rules." might be that turns into certifications as smartly, and we go down that direction.

connected: ONC Chief Delves Into everything You want to learn about data blocking Rule

HL: What key expertise challenges are hospitals and fitness methods facing regarding telehealth, and how will ONC assist?

Tripathi: i suspect that the key issues that they're dealing with are workflow and integration challenges, which is to assert that no one desires to be in two diverse techniques. A patient may also or may additionally no longer care. if you're on the affected person side, you get a hyperlink, and you simply click on the hyperlink. You have no idea that it be in the issuer's EHR equipment, or even if or not it's a unique gadget, so long as that general practitioner is on the different end in case you click on the hyperlink, it's all you in reality care about.

however from the provider facet, what they want is the skill to, for example, be in a position to doc within the clinical listing when they are having this come across with you, and never be flipping back and forth, essentially. They'd like for it to be recorded as an genuine come across in the EHR. if you consider about how that may work a yr from now, you come and you say, we had a video talk over with a 12 months in the past. until that became integrated in their gadget, they literally would have had to category in, "video seek advice from," and create an come across that is like a video seek advice from, and then you have to go through all of that. If it's built-in into your device, you just click "video visit." It automatically is aware of what's going on and places in that tips, after which permits you to document the medical checklist as you could possibly consistently. after which it be all built-in, identical to a mobile come upon for like an everyday come across. So or not it's often these workflow concerns, i think.

additionally from a [privacy] standpoint, at all times wanting to recognize that it meets the HIPAA safety rule. There was a temporary suspension during the general public health emergency, in order that people might use regular commercial solutions, like FaceTime and others, but when this goes forward, I suppose there will be a question of [whether there] are there specifications or [other] things that are necessary. If this goes ahead as whatever thing that is more enduring, and the general public health emergency is lifted, we may additionally go again to claim, "smartly, those options do deserve to meet the HIPAA protection rule, which will be an OCR (office for Civil Rights) and CMS determination." Then again, ONC might come into play at that element to assert, "How would one examine that?"

HL: How can the patient id problem be solved once and for all? affected person matching efforts seem countless.

Tripathi: Oy vey. The affected person identity query is a extremely pleasing one. As we be aware of, the Congress has, due to the fact that 1996, averted using federal dollars for a regular patient identifier that was identified within the long-established HIPAA legislation. And there seems to be feasible move in the Congress, most likely towards disposing of that ban, but that ban is in vicinity. I feel we will, at least for now, say that isn't going to be whatever that comes from the federal executive. but it doesn't avoid a voluntary identifier, as an example, getting used out there, if it got broad adoption. It would not stay away from or ban a established identifier it is supplied with the aid of the private sector, What it bans is federal funds getting used toward a generic identifier. so that can be one pathway to attending to one.

There are a couple of businesses out there that already declare that they have got a special identifier for each particular person within the country already, because they do clearinghouse functions, or they do credit score background form of records.  they may be already making that claim. So there are some styles of options available at this time. they're now not extensively adopted for in all probability quite a lot of explanations.

some of the things that we need to bear in mind is that a general identifier, even if it bought magically created the following day—as a result of now we have now had to spend, since 1996, all of those years constructing other ways to do patient matching—it is rarely as if that could be a magic wand that solves all matching complications. if you're a health center device, for example, you've already invested in expertise and procedures to do this matching. And now, in case you believe about that, I may use seven, eight different data categories to suit [a patient]. i'd use your first name, your ultimate name, your center identify, your handle, your birthdate, and maybe your cellular telephone quantity. So I've already obtained a technology that type of does that, and it does it pretty well. It would not do it completely. It does it fairly neatly. I've invested as a great deal as I feel makes sense.

Now the well-known identifier comes alongside. the first factor that happens across the business is that everyone has to spend extra cash to contain that customary identifier in their device. So every provider gadget now has to comprise all has to be promulgated, and they have to alter their processes now to accommodate that popular identifier. Then the query is, "How a lot does that can charge the trade? And where are we going to beginning to see the benefits?" it is why I suppose it's a bit bit of a challenge as smartly. that's no longer a magic in a single day answer to affected person matching problems, and we nevertheless might face adoption issues, besides the fact that one magically appeared. That doesn't mean that it wouldn't be valuable. I feel it could fully be effective. but there are challenges because we have now needed to come up with alternative ways of doing it. these other ways aren't ultimate, however are sufficient solutions, in many situations, as imperfect as they're.

Scott Mace is a contributing author for HealthLeaders.

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